Symposium Celebrating Women Surgeons Around the World

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UCSF endocrine surgeon Sanziana A. Roman, M.D., FACS, was the organizer of a symposium centered on the experiences of women surgeons from around the world. In an article published in the December 2018 edition of the World Journal of Surgery, seven women surgeons drawn from diverse geographical backgrounds recounted their personal stories told in compelling narratives.

Dr. Roman is professor of surgery in the UCSF Division of General Surgery. She also holds the positions of Director of Learning and Teaching in the Procedural Specialties and Dean’s Diversity Leader for Leadership Equity and Inclusion in the UCSF School of Medicine.

Following are excerpts of the article including Dr. Roman's own personal story.

Introduction

We must thank Dr. Sanziana Roman for organizing this symposium about women in surgery. Powerful testimonials from women surgeons, from Europe to the United States, from Africa to Australia and Asia. Each of them is different, as it reflects the culture of the place where their career took place. However, they all have in common the struggle to establish themselves in the surgical profession, traditionally a male-dominated field.

Over the last two decades, the situation has clearly improved. Today in most medical schools about 50% of the students are women, and a similar percentage is present in many surgical residency programs. Twenty-one Departments of Surgery in the United States are led by women, a major change as compared to only 5 years ago. Much more must be done to establish a work environment where women are as welcomed and respected as men; where they are accepted as surgeons, and not as women surgeons, treasuring the contribution they can give.

We do hope that this symposium will be inspirational for women and men in the surgical field and be enlightening and educational for all, promoting a culture of collegiality and mutual understanding. The glass ceiling has been cracked, it is now time to break it for good.

I am an American surgeon

Sanziana Roman MD FACS, USA

The patient had a large cortisol producing adrenal adenoma, and the retroperitoneal tissue was difficult to negotiate. I was performing a posterior retroperitoneoscopic adrenalectomy in our usual endocrine surgery operating room. As I was operating, I mentally acknowledged a proud moment in noting that, on this particularly salient date, March 8 2017, with the exception of the assisting junior resident, all other people in the room were women. As the case proceeded, I noticed that the resident became distracted by two men who had entered the room without any warning and started speaking to him directly.

“Hello, Dr Roman. We are visiting surgeons from X, and are hoping to observe this operation, since we have not seen this approach before.” The resident was embarrassed. “I am sorry, but I am not the attending; she is.” he said and pointed toward me. I looked at the visiting men and greeted them “Hello! You are welcome to stay and watch, we just started the case.” The men seemed confused. They stared at me for a moment, said “Thank you”, walked out of the room, and never returned. It was a surprising move. “I suppose they figured they didn’t really have anything to learn from a woman.” I said loudly, and continued the operation.

I entered medical school in the mid-1990s with a clear goal of becoming a surgeon. My family was not supportive. “Why don’t you chose something nice and more suited for a woman?” my grandmother would ask. Being unconventional was just fine with me, and I never regretted my decision. I always felt that as long as I shared some of the attributes of surgeons, such as dexterity, cognition and a dose of fearlessness, this career path was a good fit for me. Residency felt like an equalizer for men and women. We all worked hard, much like soldiers in trenches; we covered and cared for each other, and felt a camaraderie that was unparalleled. The work was hard and the hours long. On-call nights were mostly every other or, at best, every third. The earliest we ever went home after a call night was 7 p.m. the following day. Depressive symptoms and burnout were common among residents, and we more often confided in each other rather than discuss it with the residency director or seek professional counseling. There was significant fear of being stigmatized, seen as weak, and potentially having negative effects on one’s career. We knew that many medical licensing questionnaires ask specifically about having been diagnosed with mental problems, and none of us would ever want to have to acknowledge that. Despite changes in resident hours and efforts to remake training programs over the last couple of decades, depression rates in residents do not seem to have changed much. In a recent prospective longitudinal study by Guille et al. which assessed 3121 interns across all specialties from 44 medical institutions, including almost half women participants, depressive symptoms markedly increased during the internship year and were significantly higher for women than men [1]. Work-family conflicts accounted for a large component of this increase, and had a much stronger effect on women than on men.

Important life events during surgical residency, such as marriage and having children, were very different for women and men. During my training, most women I knew were single, and having a child during residency was taboo. While having a family and children during residency is more common today for women in training, it comes at a significant price. In one of the most in-depth cross-sectional and longitudinal surveys of surgical trainees in the U.S. including most approved residency training programs and more than 4000 general surgical residents, the National Study of Expectations and Attitudes of Residents in Surgery (NEARS), researchers were able to cull valuable information from residents over several years [2]. Compared with men, women in postgraduate years (PGYs) 1–5 were less likely to be married (28.2–47.3% vs. men 49.6–67.6%) or have children (4.6–18.0% vs. men 19.0–45.8%) (P < .001). Women who married during PGY1-3 had more concerns about their performance at work, while men who were married were more likely to be happy at work. Women who had a first child during PGY1-3 were more likely to feel overwhelmed and worry about financial security than other women, and be less happy to be at work. Conversely, men who had a child were more likely to feel supported by the faculty, compared to those who did not have children [3, 4].

In a recent follow-up, 8 years after the initial NEARS survey administration, the researchers found that nearly a quarter of categorical general surgery residents do not finish their training, and they were able to determine which surgical residents were most at risk for attrition [5]. Being a woman was independently predictive of non-completion, however there were several programmatic and personal characteristics which were associated with this. For example, the lowest non-completion rate for men was among interns at small community programs who were White, non-Hispanic, and married (6%). The lowest non-completion rate for women was among interns training at smaller academic programs (11%). The highest attrition occurred at large programs with more than seven chief residents, and being a minority woman with family close by was a strong predictor of non-completion.

These studies underline some of the difficulties women encounter in becoming surgeons. However, what they cannot measure are the daily impediments, the macro- and microaggressions which slowly accumulate over time. Yes, after nearly two decades of being a surgeon, I still get confused for being a nurse by patients and other doctors. I eventually developed a comeback for being called a “nurse”, which I use even today: “I am not the nurse, I am the surgeon, but thank you for the compliment.” If I walk in the hallway and cross paths with a male colleague, there is a low chance that he will say “hello” to me first. If I do not say anything, we pass without greeting each other. This does not happen when I encounter other women colleagues. If I walk with a male colleague and encounter another male surgeon, it is much more likely that there will be a greeting initiated than if I was walking alone, often with the acknowledgement glance toward the male, first, then me. I notice these things because they have been recurrent and persistent over time; small as they may seem, unconscious perhaps, these microagressions contribute to a culture of isolation, and a sense of lack of camaraderie.

Over the years, I have come to realize something important. I am not just a surgeon. I am a “woman surgeon”. What does that mean? As a woman surgeon, I feel I must fit certain gender expectations, otherwise, I may be punished. For example, there is always the expectation that I would be friendly and in a good mood. I should be chatty on the floors with the nurses and the patients. I need to be relatable, however, too much friendliness, and I lose my authority as a surgeon. There is a very fine line which has to be walked, and, as a woman, I am aware of this every waking moment of my professional life. Don’t be too forceful, but don’t seem weak; be friendly, but don’t let them take advantage of it. Smile no matter what, otherwise I will be viewed as cold. In other words, I better comply with gender norms and schemas. This expectation has been studied and reported in other specialties. A meta-analysis of 45 studies—including more than 100,000 patients (70% of whom were female), and over 4000 physicians (one-third female)—assessed whether there was a difference in patients’ satisfaction with male versus female physicians [6]. Patients generally appreciated a “patient-centered” encounter, often rating highly time spent with the physician, if the physician listened more, and seemed to have compassion. These traits have been shown to be more often associated with women physicians; however, patients assimilated the “patient-centeredness” in female physicians as expected female behavior, and did not see it as a sign of a “good physician”, yet gave male physicians who displayed patient-centered qualities “better doctors” evaluations. As a consequence, female physicians did not get appropriate credit for being professionally competent, and had lower patient evaluations relative to male physicians for similar behavior.

I have experienced this in my professional life as well. On numerous occasions, patients listen carefully to my explanations, my diagnostics, the description of the surgical procedures, possible complications, recovery, prognoses, and at the end of our time together, they ask “So, who will be doing my surgery?” Engrossed in their concern and focused listening, they seem to forget who I am, and seem surprised when I remind them that I AM the surgeon. The “woman surgeon”. And then, they understand.

Having complications as a woman surgeon is worse than for male colleagues. This has been shown in a recent study from Harvard which studied whether a surgeon’s gender influenced the way referring physicians interpreted their ability, and documented the implications for gender inequality in surgery [7, 8]. The researcher analyzed Medicare data on referrals by doctors to surgeons, and then looked at what happened to doctors’ referral rates for up to 18 months after one of their patients died during a surgery. She found that referrals dropped by more than half after a patient died after having an operation by a female surgeon, yet this change in referrals was not noted when the death occurred with a male surgeon. More concerning, analyzing referral data for other women surgeons in the same specialty and the same area, the author found that a bad outcome from one woman surgeon biased referrals to other women surgeons in general; this was not seen with men. This means that having one bad experience with one woman surgeon, shaped referring physicians’ views on all women surgeons. Interestingly and corollary, using referral volumes after a surgery as the proxy for the doctors’ views of the surgeons’ talent, if a patient had a good outcome, the referring physicians were more optimistic about a male surgeon’s ability, than about a female surgeon’s ability.

This type of bias can account to some degree for other inequalities between women and men surgeons. Professional recognitions, awards, and invitations to give prestigious grand rounds or lectures have been noted to lag behind for women surgeons. Even the simple way that women speakers may be introduced is more often by their first name rather than by their professional title. This phenomenon came to mainstream attention with several articles, including one in the Washington Post which highlighted a study by Files et al. who retrospectively analyzed videotaped grand rounds speakers at two different locations of the Mayo Clinic academic departments of medicine and noted how the professional title of the speaker was used in presentations and introductions [9]. In more than 300 instances, female introducers were more likely to use professional titles when introducing any speaker during the first form of address compared with male introducers (96.2 vs. 65.6%; p < 0.001) [10]. Females introducing female speakers utilized formal titles nearly all the time compared with males introducing male speakers (75% of the time). When the introducer was female and the speaker male, formal titles were used nearly all the time, while male introducers of female speakers utilized professional titles in less than half of instances. I personally have experienced this multiple times, not just at introductions of presentations, but also during meetings and conferences. Usually, a senior male member of the department would routinely call me by my first name during professional public meetings, while calling other men colleagues by their formal “Doctor” name. What made it worse was that he would mispronounce my name repeatedly, even though we had worked together for more than a decade and I had tried to correct him in private. Many may think this is a small thing. I disagree. Words are powerful, and their implications are not lost on those who listen. The perception is that of lesser status, competence or expertise. These microaggressions are a strong warning signal of stalling the trajectory of women’s career path, rate of advancement to leadership positions, promotions and compensation.

My salary has always been lower commensurate to that of my male peers. When a woman starts her first job at a lower salary, this number will impact future remuneration; it anchors one at a certain place and makes it very difficult to jump ahead. When a woman negotiates for herself, she is seen as aggressive. Negotiation is not a gender appropriate behavior, and women may be punished for it, both by men and other women. Behavior which is seen outside of societal norms for a woman will lead to negative effects. This is just one of the implicit biases which are common in medicine and surgery. Two recent comprehensive studies on physician incomes have demonstrated large and increasing disparities by gender. In the first annual physician compensation report in April 2017 by Doximity—which is the largest social network in medicine, with 70% of all U.S. physicians as members—the gender pay gap in reported compensation of more than 36,000 physicians showed 20% lower pay for women in surgical specialties [11]. A second recent study analyzed the salaries of more than 10,000 academic physicians working at 24 public medical schools. The authors showed that, after adjusting for demographics, faculty rank, scientific authorship, NIH funding, clinical trial participation and Medicare reimbursement, among 1334 surgical specialty faculty, women made less than men by $12,000–65,000 per year, and the gap has been widening over time [12]. Many explanations have been put forth as to why this disparity persists. Differences in clinical volumes have been cited often. Factors which may lead to lower clinical volumes include women spending more time with each patient in clinic than men; higher household and child-rearing responsibilities for women, sometimes necessitating possible part time work; greater difficulty in finding mentors; inequitable allocation of institutional resources, such as nurses, administrative assistants, space; fewer opportunities for advancement; implicit or explicit bias; lower salary negotiation for women, among others. I believe that women start their careers at a lower salary, and over time, fall behind more and more, given many of the reasons enumerated above. The fact that salary disparities exist in most professions in society will only make achieving equity harder. For example, even in tennis, where very prominent players often are equally popular, Roger Federer was paid for winning a tournament more than $731,000, while Serena Williams made $495,000 for winning the same tournament [13].

While we have encountered many challenges, there are many benefits to being a woman surgeon in America today. With several great “pioneer” women having paved the way, the path to progress is widening. The American College of Surgeons has named three women presidents within the last 12 years, including the current president. The number of women who serve as Chairs of Departments of Surgery in the U.S. is now at 21, having rapidly increased over the last decade. Several national societies, including venerable ones who have traditionally been male dominated, understand that diversity and inclusion in surgery is not only inevitable, but long overdue and advantageous. Culling talent universally from among all genders (cis-, trans-, pan-, a- or gender fluid), and opening new opportunities equally will make our profession much stronger, drive forward science and discovery faster, and ultimately help our patients have better outcomes. Societies such as the Association of Women Surgeons, the American Surgical Association, and the American College of Surgeons, to name a few, are not only bringing awareness about the difficulties of women surgeons, but are actively working toward better integration and promotion through organized courses for women surgeons and trainees in leadership, negotiations and career development. Sponsorship and mentorship for women has become more widely available. Social media platforms, such as Doximity, Facebook, and Twitter, have created national and global arenas of communication, activism and engagement. Movements such as #ILookLikeASurgeon, #HeforShe, #NYerORCoverChallenge have brought together thousands of women and men participants from across the globe and have allowed us all to have a voice in ways which I could not even imagine 20 years ago. While much work remains to be done, the progress is palpable, and there are many women and men surgeons who understand that together we can build a more equitable and better world for the future.

As I finished the operation, and left the OR to speak to the patient’s family, I thought about my encounter with the visiting surgeons. I was sad that they had denied themselves an opportunity to see women surgeons in a different way. As I walked the hall, lulled by the rhythmic tapping of my wooden silver OR clogs, I was startled out of my reverie by the cheerful voice of a male nurse calling loudly behind me: “Happy International Women’s Day, Dr. Roman!” “Thank you”, I said with a smile.